Greeting
Good day, dear Professor Doctor …,
I would now like to present the patient Ms. Beate Schreiber to you.
She is 36 years old, 1.72 meters tall and weighs approximately 80 kg. The body mass index (BMI) is 27 kg/m² and thus falls into the overweight range
Presenting complaint / current history
The patient presented as an emergency due to an episode that occurred about four hours earlier, paroxysmal dyspnea with a feeling of suffocation to our department. She also reported an irritating cough, tachypnea, expiratory wheeze and a pronounced state of restlessness.
As a result of the repeated coughing, the patient complained of pleuritic chest pain.
The following complaints are absent: fever, sore throat, dysphonia, rhinoconjunctivitis, irritation in the throat, hemoptysis, orthopnea, tachycardia, nausea, emesis, cervical lymphadenopathy, gastrointestinal complaints and rash.
Rarely there is clear, transparent and slightly glossy sputum.
According to her report, the attack lasted about 20 minutes, with the complaints being particularly severe for about 10 minutes. The symptoms only partially improved.
(She stated that there had been two similar attacks since yesterday – one during a car ride in a tunnel while stuck in traffic, which improved after leaving the tunnel and opening the window, and another around 3 to 4 a.m. while sleeping. During that episode, the bedroom window had already been open.)
The history reveals a childhood diagnosis of airway hyperreactivity.
Previous episodes, however, were significantly milder in duration and intensity. She reported that she often has to cough or sneeze during walks in the woods, especially in spring.
Autonomic history
The autonomic history is unremarkable, aside from a targeted diet avoiding gas-producing foods such as legumes and cabbage to alleviate flatulence and postprandial bloating.
There is also insomnia in the form of difficulty falling asleep, which the patient associates with a miscarriage six months ago.
Past medical history
The following past medical conditions are reported:
The patient reports recurrent complaints since childhood in the external acoustic meatus in the form of pruritus, xeroderma and scaling.
She cites triggering factors in particular as water contact (e.g. when swimming) and mechanical irritation from cotton swabs.
In the winter months there is pronounced drying of the skin on the hands with occasional fissureformation.
The patient reports having had a painful felon on the right middle finger about two months ago.
Therapeutically an incision and irrigation were performed, followed by the application of a moist ethacridine lactate dressing.
Subsequently the affected finger was immobilized with a plaster splint.
The patient also reports chronic cervicalgiafor about five years, which, according to orthopedic assessment, is work-related due to prolonged sitting.
Seven years ago the patient sustained a zygomatic fracture on the left side as a result of a direct trauma from a volleyball impact.
The fracture was treated conservatively.
Previous surgeries / procedures
Four years ago the patient injured her right knee while playing volleyball. Because the complaints persisted, an MRI was performed which detected a loose body (arthrolith) which was subsequently treated.
About six months ago the patient experienced a miscarriage in the 11th week of pregnancy.
An ultrasound examination showed an absent fetal heartbeat.
This was followed by, under local anesthesia , a curettage. No complications occurred.
Note: If a statement can be objectively confirmed by a medical examination – for example by visible scars – the indicative is appropriate. (No physical examination takes place in the Fachsprachprüfung.)
Gynecology
Her last menstrual bleeding was eight days ago.
The cycle is regular and there are no notable complaints.
As a contraceptive the patient has been using a transdermal patch (Lisvy) for 2 months.
Medications
The following medications are listed on her prescription:
Currently the patient is taking the following medications per prescription:
topical corticosteroid ointment as needed to treat an eczema on the ear or hand
Ibuprofen 400 mg as needed
Note: If a statement can be objectively confirmed by a physician’s observation – for example by a prescription – the indicative is appropriate.
Allergies
The patient reported a seasonal pollen allergy in spring with symptoms of rhinoconjunctivitis and a food allergy to nuts, especially hazelnuts and walnuts, which manifests as oral paresthesias in the area of the lips and tongue.
Substance use / noxious agents
Regarding the consumption of recreational substances, the patient stated that she is a non-smoker.
She drinks occasionally, on special occasions, one to two glasses of beer.
For about three months she has occasionally used joints.
Social history
The patient works as an environmental technician and lives with her partner. A marriage is planned soon. She has no children.
Family history
The family history included several relevant parental pre-existing conditions. The patient’s 76-year-old father has been suffering for about eight months from an advanced pancreatic carcinoma. Because of the tumor stage, only pain therapy is being provided as part of palliative care. The history includes a long-standing alcohol abuse.
The 72-year-old mother lives in a nursing home due to an advanced dementia . At the age of 52 she underwent surgery for an abdominal carcinoma that had clinically presented, among other things, with heavy vaginal bleeding and abdominal pain. At times there was a scotoma in the right eye.
(Please note: Context always takes precedence. Writing an entire section in Konjunktiv I or expressing it that way is really a nightmare!)
Suspected and differential diagnosis
The anamnesis — in particular paroxysmal irritating cough and dyspnea against the background of known airway hyperresponsiveness as well as accompanying atopic conditions such as eczema and seasonal rhinoconjunctivitis — clinically point to the presence of bronchial asthma.
Differential diagnoses include viral infections of the upper or lower respiratory tract as well as bacterial pneumonia. However, the absence of fever, the lack of other constitutional symptoms and the paroxysmal course argue against these.
Bronchitis can occur following a viral infection; the course is usually self-limiting and improves spontaneously.
In pneumothorax, sudden-onset dyspnea and sharp thoracic pain are to be expected.
Chronic obstructive pulmonary disease (COPD) is unlikely in this patient, however, since there is no history of tobacco use, no relevant dust exposure and the patient’s age is not typical for this diagnosis.
Although the use of hormonal contraceptives increases the risk of deep vein thrombosis (DVT), the clinical course and the absence of typical symptoms such as leg pain or edema argue against this suspected diagnosis.
Heart failure is also unlikely, as there are neither cardiovascular risk factors such as tobacco abuse, arterial hypertension or diabetes mellitus, nor is the patient’s age typical for this.
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Additional knowledge |
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The main symptom of bronchial asthma is increased airway resistance, which is caused by obstruction of the airways. This arises from contraction of the bronchial smooth muscle, thickening of the bronchial epithelium and lumen narrowing due to secretions. Asthma symptoms occur mainly during exhalation because intrathoracic pressure increases during expiration and further compresses already narrowed bronchi. |
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The atopic triad typically consists of atopic dermatitis (skin), bronchial asthma (airways) and allergic rhinitis (nasal mucosa). |
Diagnostic workup
The patient should initially be admitted to hospital and immediate initial therapy should be started.
This primarily includes administration of oxygen, possibly supplemented by inhaled bronchodilators (e.g., salbutamol via nebulizer) and, if needed, systemic glucocorticoids to reduce bronchial inflammation.
physical examination
After the history we perform a thorough physical examination. This begins with recording the vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation and body temperature.
This is followed by a targeted clinical examination, starting with inspection. We look for various abnormalities such as signs of atopy, including atopic dermatitis (e.g., dry skin, eczema) and allergic rhinoconjunctivitis. Additionally, we assess the oral cavity and pharynx as well as the breathing pattern, particularly for signs such as use of accessory respiratory muscles or a prolonged expiratory phase. Cyanosis may occur in severe courses.
On percussion a hyperresonant percussion note is typically found — especially over overinflated lung areas due to bronchial obstruction, as can occur in bronchial asthma.
Auscultation usually shows expiratory wheeze (whistling)/ expiratory stridor as well as altered, partly diminished or bronchial breath sounds. typically presents with an expiratory wheeze (whistling)/ expiratory stridor, as well as altered, partly diminished or bronchial breath sounds.
In pneumothorax percussion typically reveals a hyperresonant note over the affected hemithorax. Auscultation shows diminished or completely absent breath sounds over the affected lung area.
In contrast, in pneumonia percussion reveals a dull percussion note over the inflamed lung segment. Auscultation typically yields fine crackles, increased bronchial breath sounds and possibly increased bronchophony.
Laboratory tests
Laboratory tests are generally not mandatory, since the diagnosis of bronchial asthma is made primarily clinically and with the help of spirometry.
Arterial blood gas analysis (ABG), differential blood count, CRP, total IgE level.
Skin test procedures for allergy diagnostics
In a prick test a small amount of an allergen is applied to the skin.
In an intradermal test a small amount of the allergen is injected directly into the skin.
The patch test is used to diagnose contact allergies. A patch coated/covered with an allergen is applied to the skin for 24 to 48 hours.
Anatomic diagnosis
Chest X-ray:
A chest X-ray is an imaging examination in which structures of the thoracic cavity are depicted using X-rays.
Typical radiological findings in bronchial asthma can include pulmonary hyperinflation with flattened diaphragms and increased retrosternal lucency; however, chest X-ray findings are often unremarkable.
Before the examination the patient removes jewelry and clothing in the chest area.
The image is usually taken in p. a. projection (posteroanterior) in upright position. The patient stands facing the X-ray plate and is instructed to take a deep breath and briefly hold it to avoid motion artifacts.
Spirometry
In symptomatic adults and children over five years who can perform spirometry, pre- and post-bronchodilator spirometry is the recommended first-line diagnostic method.
Spirometry is a lung function test in which the patient breathes in and out through a mouthpiece into a device (spirometer).
The typical procedure is as follows:
1. Baseline measurement (pre-bronchodilator):
The patient inhales deeply and then exhales forcefully and rapidly (forced expiration).
2. Administration of a bronchodilator (e.g., inhaled salbutamol)
3. Repeat measurement (post-bronchodilator) after about 15 minutes to assess reversibility of airway obstruction.
In bronchial asthma, spirometry typically shows an obstructive ventilation pattern with reduced FEV₁ and FEV₁/FVCratio (< 70%).
Characteristic is a significant reversibility of the obstruction after bronchodilator administration (↑ FEV₁ ≥ 12% and ≥ 200 ml).
|
Parameters |
Value before bronchodilation |
% predicted |
Value after bronchodilation |
% predicted |
Assessment |
|
FEV₁ |
2.1 l |
65 % |
2.7 l |
84 % |
markedly reduced, reversible |
|
FVC |
3.5 l |
88 % |
3.7 l |
93 % |
normal to mildly reduced |
|
FEV₁/FVC (Tiffeneau) |
0,60 |
– |
0,73 |
– |
↓ before BD, normalized after BD |
|
PEF |
5.2 l/s |
60 % |
6.8 l/s |
78 % |
markedly improved |
|
MEF25–75 |
1.5 l/s |
45 % |
2.6 l/s |
75 % |
Indication of small airways |
|
Airway resistance (RAW) |
increased |
– |
reduced |
– |
suggests bronchoconstriction |
|
Flow-volume curve |
concave expiratory limb |
– |
significantly improved |
– |
typical for asthma |
|
Reversibility |
– |
– |
+600 ml / +28 % FEV₁ |
– |
positive |
For classification of bronchial asthma, among other things, the frequency of symptoms on weekdays, nocturnal complaints and spirometric parameters are considered.
Whole-body plethysmography
Body plethysmography is not required if the diagnosis can be made clearly by history and spirometry.
Whole-body plethysmography (also body plethysmography) is an advanced lung function test that allows precise measurement of lung volumes and airway resistance.
The patient sits in an airtight chamber during the examination and breathes in and out through a mouthpiece. Pressure and volume changes in the chest are recorded.
Unlike spirometry, which only records mobilizable lung volumes (e.g., FVC, FEV₁), whole-body plethysmography also allows determination of total lung capacity (TLC).
Peak flow meter
A peak flow meter is a handy device used to measure the maximum expiratory speed or peak expiratory flow (PEF).
Computed tomography
A CT can be useful when there is suspicion of differential diagnoses, e.g., bronchiectasis or tumors.
Consultations
Surgery / trauma surgery consult as well as anesthesia consult
Treatment
Non-pharmacological therapy for bronchial asthma
• Avoidance of triggering factors
(e.g., allergens, tobacco smoke, cold air, air pollution, occupational exposures)
• Promotion of regular physical activity
• Patient education
pharmacological therapy
All patients with asthma should be prescribed a fast-acting β₂-agonist (e.g., salbutamol) as needed (reliever) that can be used in acute bronchial obstruction.
In addition, patients should be trained in the correct use of the inhalation device to ensure effective drug delivery.
Regardless of the active substance used, the emergency medication should consist of two puffs of the inhaler, with an interval of 3 to 5 minutes between the first and second puff.
Stepwise therapy for bronchial asthma
• Step 1:
As-needed therapy with low-dose inhaled glucocorticoid (ICS) + short-acting β₂-agonist as needed (SABA, e.g., salbutamol)
• Step 2:
Daily use of a low-dose ICS + SABA as needed
• Step 3: Symptoms daily, nocturnal symptoms > 1× per week; limitation of activity; FEV₁ 60–80 %
Daily low-dose ICS-LABA combination + SABA as needed
• Step 4:
ICS in medium to high dose + LABA + SABA as needed
• Step 5:
Daily high-dose ICS-LABA combination + consultation with a specialist for escalation with e.g., tiotropium, anti-IgE, anti-IL-5/5R, anti-IL-4R
Inhalers:
• Salbutamol (blue): short-acting β₂-agonist (SABA)
• Foster (light purple): beclometasone (ICS) + formoterol (LABA)
• Symbicort (red): budesonide (ICS) + formoterol (LABA)
• Seretide (purple): fluticasone (ICS) + salmeterol (LABA)
• Tiotropium (Spiriva) (green): long-acting muscarinic receptor antagonist (LAMA)
Inhaler use
• Shake the inhaler well.
• Hold the inhaler upright and remove the protective cap from the mouthpiece.
• Exhale deeply (not into the inhaler) and then place the mouthpiece firmly between the lips.
• Begin to inhale slowly and deeply through the mouth. Simultaneously press the canister to release a spray and hold your breath for about 5–10 seconds.
• rinse the mouth
Complications
• Status asthmaticus (life-threatening, prolonged attack)
• “Status asthmaticus” is a life-threatening asthma exacerbation that does not respond to the usual initial measures with bronchodilators and corticosteroids
• Pneumothorax
• Irreversible bronchial obstruction
• Reduced quality of life (exercise tolerance, sleep quality)
• Growth retardation (in children, rare)
Medical orders
Monitoring
• Vital signs: BP/HR/RR/Temp/SpO₂ on admission, then every 2–4 h, continuously if unstable.
• Readiness for intubation in impending respiratory exhaustion
• After stabilization, appointment for spirometry.
• Warning signs (silent chest, speech dyspnea, cyanosis, loss of consciousness).
Diagnostics
• ABG (arterial or capillary) on admission
• Laboratory: blood count, CRP, electrolytes, creatinine, glucose (possibly troponin and BNP with corresponding differential diagnosis and possibly β-HCG).
• ECG (tachycardia/β₂-agonist effects, cardiac DD).
• Chest x-ray for unclear findings, severe course or DD (pneumothorax, pneumonia).
• Virological/infectious swab only with clinical suspicion
Therapy
Oxygen
• O₂ via nasal cannula 1–4 l/min
SpO₂ target: 92–96 % (different in known CO₂ retention).
• Elevation of the upper body
Bronchodilation (acute)
• Salbutamol nebulizer 2.5–5 mg (or 4–8 puffs of 100 µg via spacer) every 20 min × 3, then every 2–4 h or as needed.
• Ipratropium bromide nebulizer 0.5 mg every 6–8 h in the first 24–48 h.
Systemic glucocorticoids
Prednisolone 50 mg p.o. (or 100 mg i.v.) once now, then 40–50 mg p.o. once daily for 5–7 days, no taper required for short course.
Further
Patient education on correct inhalation technique and trigger avoidance, review of rescue medication, pulmonology consult for therapy adjustment.
Extra
Names:
Karl Lauterbach, Beate Steurmann, Andreas Teufel, Mario Dietrich, Alexa Frank
Details:
When asked about folic acid, I did not know what to say, but the patient said — her gynecologist had prescribed it to prepare for the next pregnancy.
his fiancée lost a child eight months ago. Their wedding is planned in three quarters of a year.
The patient reported having had three similar complaints since the beginning of spring, each time more pronounced. Previously he had noticed no such symptoms. Currently there are no complaints; these occur exclusively while staying in the forest.
The patient is homosexual. (Important with regard to HIV, HBV, HCV and other sexually transmitted diseases.)
Bus driver
Tram driver
Makeup artist (cosmetics/beauty)
Pre-existing conditions/ Medications:
Removal of eye bags 2 years ago
Arterial hypertension for five years
Hearing aid user bilaterally (hypoacusis)
Status post appendectomy at age 12
Measles
Mumps
Status post osteosynthesis of the right wrist following a bicycle accident 13 years ago
An over-the-counter cold medication.
Whooping cough (pertussis)
Chickenpox (varicella)
Exforge® 1-0-0 (contains amlodipine / valsartan, please add dosage, e.g. 5 mg / 160 mg)
Cetirizine 10 mg 1 tablet as needed
Valsartan 80 mg 1-0-0
Ramipril 5 mg 1-0-0
Family history:
A daughter of a former partner who suffers from autism.
The mother suffers from arterial hypertension and urticaria.
The father has obesity and a gambling addiction.
The patient has three siblings (two sisters and one brother).
One sister suffers from dementia and lives in a nursing home.
The other sister and the brother have a blood sugar problem, probably diabetes mellitus.
The mother suffers from multiple sclerosis and nephrolithiasis.
The father has obesity and ludopathy; there is no contact with him.
The sister suffers from arterial hypertension.
The father has a gambling addiction. (He wastes his money)
Brother: Parkinson’s disease
Allergy:
Hazel pollen, flour dust
Drugs:
LSD
Ecstasy
Questions
1. How do you recognize carbon monoxide poisoning, for example in a traffic jam? What exactly is it, how is it measured, and at what level does it become dangerous?
Carbon monoxide intoxication occurs from inhaling carbon monoxide (CO), e.g., from a running engine in an enclosed space or in a traffic jam with poor ventilation. CO binds with high affinity to hemoglobin and prevents oxygen transport. It is diagnosed by measuring the CO-Hb level in the blood (carboxyhemoglobin). It becomes dangerous at about 10–15% CO-Hb – higher values risk unconsciousness, respiratory arrest and death.
2. What does nebulization mean?
Nebulization refers to the atomization of a liquid medication into fine droplets (aerosols) so it can be inhaled through the airways.
“Salbutamol was administered by nebulization.”
3. What does impotent mean?
A man is impotent if he cannot achieve or maintain an erection sufficient for sexual intercourse.
4. How is blood taken?
Preparation:
Inform the patient and obtain consent, perform hand disinfection, put on gloves.
Prepare material:
Tourniquet, needle/butterfly, blood collection tubes, swab, plaster, disinfectant, sharps container
Puncture site:
Usually in the crook of the arm (median cubital vein).
Puncture
Insert the needle into the vein at an angle of about 30°.
5. What is desensitization, and how is it performed?
Desensitization (also: specific immunotherapy) is an allergy-specific treatment in which the body is gradually habituated to the allergen to reduce or prevent the allergic reaction.
The allergen (e.g., pollen, house dust mites, insect venom) is administered to the patient in increasing doses. It usually lasts 3–5 years.
6. In which countries is the prevalence of tuberculosis higher, and why is tuberculosis more common there?
According to the World Health Organization (WHO Global Tuberculosis Report 2024), over 85% of all TB cases occur in 30 high-incidence countries, including India, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh, South Africa and China.
7. How is asthma classified, and which type occurs most frequently?
Asthma is divided by cause into allergic (extrinsic) and non-allergic (intrinsic) asthma.
Allergic asthma occurs most frequently.
In addition, asthma can be classified by severity as intermittent, mild, moderate and severe persistent.
Notes
BMI
BMI — Definition
The body mass index (BMI) is a dimensionless measure to estimate body weight relative to height. It is calculated by dividing body weight in kilograms by the square of height in meters (kg/m²).
Limitations
emergently
Emergently — Meaning
The term describes actions or considerations that require immediate assessment or intervention due to an acute medical emergency. In the clinical context, the term implies a timely, prioritized approach after initial assessment and possibly rapid therapeutic response.
paroxysmal
Paroxysmal — Meaning
“Paroxysmal” describes a sudden, often short-lived or recurrent onset of symptoms. Typical features are rapid onset and possibly an equally abrupt end of the complaints.
Dyspnea
Dyspnea — Definition
Dyspnea refers to the subjective experience of breathlessness or difficult breathing. Affected individuals describe a sensation of breathing effort, lack of air or inadequate air intake.
Sensation of suffocation
Sensation of suffocation — Meaning
The sensation of suffocation describes the subjective feeling of not getting enough air or that breathing is obstructed. Patients may describe this as tightness, gagging or acute breath-holding.
Distinction and causes
This sensation can occur with partial airway obstruction (e.g., foreign body, swelling), bronchospasm, pronounced anxiety or other acute disturbances of respiratory function; it differs from objective respiratory insufficiency, which can be proven by investigations.
Tachypnea
Tachypnoea — definition
Tachypnoea denotes an increased respiratory rate. In adults it is frequently considered a respiratory rate above about 20 breaths per minute, although threshold values vary depending on source and clinical context.
Significance
Accelerated breathing can indicate respiratory or metabolic disorders, fever, pain, anxiety or hemodynamic problems and should always be assessed in conjunction with other findings.
Dysphonia
Dysphonia
Dysphonia refers to a disorder of voice production with altered timbre, volume or pitch of the voice. Common causes are inflammatory processes of the vocal folds, functional voice overload, reflux or neurological damage. In cases of sudden onset or persistent severe dysphonia, specialist evaluation should be undertaken, as this may indicate structural or neuromuscular problems.
Rhinoconjunctivitis
Rhinoconjunctivitis
Rhinoconjunctivitis denotes simultaneous inflammation of the nasal mucosa and the conjunctiva, typically with sneezing, runny or blocked nose and red, watery eyes. Common triggers are allergenic substances (e.g. pollen, house dust mites) or, less commonly, infectious stimuli. The symptom pattern often shows seasonal or situation-dependent patterns and is classified clinically according to symptoms and triggers.
Irritation sensation
Throat irritation
Throat irritation is described as a subjective scratching, burning or foreign-body sensation in the pharynx. Causes can include viral or allergic reactions, postnasal drip, smoking, dry air or gastroesophageal reflux. For persistent or progressive irritation, an examination to clarify chronic causes is recommended.
Orthopnoea
Orthopnoea
Orthopnoea is the symptom of breathing difficulty that worsens when lying down and improves in an upright position. Typical causes are cardiac decompensation (e.g. left heart failure) or severe pulmonary disorders with fluid overload of the lungs. Distinguishing it from other position-dependent breathing problems and asking about positional dependence is diagnostically relevant.
Nausea
Nausea
Nausea denotes the subjective feeling of sickness with the urge to vomit, without necessarily having expelled contents. It can precede vomiting and is triggered by many causes, such as gastrointestinal diseases, drug side effects, vestibular disorders or systemic diseases.
Emesis
Emesis
Emesis describes vomiting, i.e. the reflexive or forceful expulsion of stomach contents through the mouth. Causes are diverse and range from infections and intoxications to vestibular disorders and metabolic diseases. Clinically relevant are possible complications such as risk of aspiration, disturbances of electrolyte and fluid balance and the indication for further investigation in repeated or severe vomiting.
Airway hyperreactivity
Airway hyperreactivity
Definition: An increased responsiveness of the airways to various physical or chemical stimuli that can lead to transient narrowing of the bronchi.
Clinical significance: Typical manifestations are cough, tightness or wheezing after exposure to allergens, cold air, physical exertion, infections or irritant substances. Airway hyperreactivity is a nonspecific feature that can occur in bronchial asthma but may also exist in isolation.
General classification: Evaluation depends on frequency and severity of symptoms; functional tests (e.g. bronchial provocation tests) and a targeted search for triggering factors are common.
Meteorism
Meteorism (flatulence)
Definition: Meteorism denotes increased accumulation of gases in the gastrointestinal tract, which can lead to a feeling of fullness and visible abdominal distension.
Causes and associations: Common causes are increased gas production from certain foods, altered gut flora, malabsorption or disturbed intestinal motility. Foods such as legumes or brassica vegetables are typically associated with increased gas production.
General measures: Dietary adjustments and identification of individually tolerated foods are often recommended for relief; further diagnostics and management include evaluation for possible food intolerances or functional disorders.
Insomnia
Insomnia (sleep disorder)
Definition: Insomnia denotes difficulty falling or staying asleep or nonrestorative sleep despite adequate opportunity to sleep.
Miscarriage
Miscarriage (pregnancy loss)
Definition: Miscarriage refers to the loss of a pregnancy before the fetus reaches viability.
Causes and course: Common causes are chromosomal anomalies, maternal diseases, anatomical uterine problems or infections; the course ranges from early spontaneous loss to later miscarriage.
Consequences and classification: A miscarriage may require physical follow-up care and diagnostic clarification; psychologically, pregnancy loss is often distressing and can trigger grief reactions, sleep disturbances or other psychosocial burdens. Professional support is advisable for persistent psychological distress.
Meatus acusticus externus
Meatus acusticus externus (external auditory canal)
Definition: The external auditory canal is the bony and cartilaginous canal that connects the auricle with the tympanic membrane and is lined by epidermal skin with ceruminous glands.
Function and clinical aspects: It conducts sound to the tympanic membrane and protects the middle ear; typical complaints are itching, scaling, pain or discharge. Common triggers for local problems are water exposure, mechanical irritation by foreign bodies or external manipulation.
Pruritus
Pruritus (itching)
Definition: Pruritus is the unpleasant sensation that typically triggers the urge to scratch.
Causes and localization: Itching can be localized or generalized and has many causes, including dermatological diseases, local irritations, infections, systemic diseases, neurological or psychogenic factors. Localized in the external auditory canal, pruritus commonly occurs with dermatoses, dry skin or external ear infections.
Xeroderma
Xeroderma — definition and significance
Xeroderma denotes increased dryness of the skin, manifested by reduced fat and moisture content. Clinically it often appears as tightness, fine scaling and itching.
Causes and associations
Common causes are climatic stress (cold, dry air), excessive cleansing with irritating detergents, age-related skin changes and atopic predisposition. Certain systemic diseases and medications can also contribute to drying.
Consequences and general aspects
Untreated xeroderma promotes fissuring, irritation and secondary infections. Preventive measures include gentle skin care, avoidance of strongly degreasing cleansers and protection from extreme environmental factors.
Fissure formation
Fissure formation — definition
Fissures are painful, slit-like cracks in the skin surface that can occur especially in exposed areas.
Causes and typical locations
Triggers are often pronounced skin dryness, mechanical stress or repeated wet–dry cycles; common sites are finger flexures, heels and corners of the mouth. Cold and eczematous dermatoses also promote their development.
Paronychia
Paronychia — brief definition and classification
A paronychia is a purulent inflammation in the area of a finger or toe that can affect various tissue layers (e.g. paronychia, felon, subcutaneous paronychia).
Etiology and development
The infection usually arises from entry of bacterial pathogens such as staphylococci or streptococci through small skin injuries. Mechanical damage or nail injuries favor colonization.
Clinical features and possible complications
Typical signs are local pain, redness, swelling and pus accumulation; if untreated it can extend to involve deeper structures up to bone involvement. Specialist care is indicated.
Incision
Incision — concept and purpose
An incision is a deliberate surgical cut into the skin and underlying structures to create access or open the interior of a pathological area.
Indications and general notes
Common reasons are opening abscesses for drainage, creating a surgical access or obtaining tissue samples. For all incisions, sterile technique, appropriate analgesia and knowledge of the underlying anatomy are important.
Possible consequences
Complications can include bleeding, infection or scarring; the exact approach depends on findings and indication.
Cervicalgia
Cervical pain — definition
Cervical pain refers to pain in the region of the cervical spine, i.e. the neck area.
Causes and typical accompanying features
Causes can include muscular tension, postural problems, degenerative changes of the spine, or nerve root irritation. Common accompanying complaints are movement restrictions, headaches, or radiating pain into the upper extremities.
General relevance
Chronic or exertion-related forms are often work-related and require ergonomic and conservative measures for symptom control and preservation of function.
Zygomatic bone fracture
Zygomatic bone fracture (fracture of the os zygomaticum) — overview
A zygomatic bone fracture affects the zygomatic bone (os zygomaticum), a bony part of the cheek region, and usually results from direct blunt force.
Clinical clues and associated findings
Typical signs include facial swelling, tenderness to pressure, possible elevation of the cheek position, sensory disturbances in the area of the infraorbital nerve, as well as limitations in mouth opening or ocular accompanying symptoms if the orbit is involved.
Assessment and possible consequences
Therapy depends on the extent of displacement and accompanying injuries; significant dislocation often requires repositioning procedures. Important complications can include cosmetic deformities, extraocular muscle dysfunction, or nerve damage.
Loose body
Brief definition
A loose body is a freely mobile intra-articular fragment moving within a joint space.
Composition and origin
They are usually detached cartilage or bone fragments (osteochondral fragments); less commonly, calcified synovial parts or other debris formations may be present.
Clinical significance
Loose intra-articular bodies can cause mechanical symptoms such as joint locking, clicking or crepitus phenomena, and pain. They can be visualized by imaging and are often removed arthroscopically if symptoms persist.
Abortion
Term and significance
The medical term abortion refers to the unplanned loss of a pregnancy before the fetus reaches the point of viability.
Temporal classification and forms
In obstetric practice, an abortion is generally understood as pregnancy loss before the defined limit of viability (conventionally before about the 24th week of gestation). A special form is the missed abortion: in this case the embryo or fetus has died intrauterinely without spontaneous expulsion having occurred.
Clinical consequences
Depending on gestational age and clinical findings, different diagnostic and therapeutic measures are considered; the term definition remains independent of the specific treatment.
Anesthesia
Overview
Anesthesia denotes procedures to suppress pain perception and/or consciousness during diagnostic or therapeutic interventions.
Neuraxial regional techniques
Spinal anesthesia: the drug is injected into the subarachnoid space (CSF space); this usually produces a rapid and dense sensory and motor block of the lower half of the body. Indications include, among others, cesarean section and operations on the lower extremities.
Epidural anesthesia (peridural anesthesia): the drug is applied to the epidural space (outside the dura mater); a catheter is often placed so that the effect can be dosed and maintained over a longer period. Onset is generally slower and intensity is better controllable.
Distinction
Local anesthesia differs in that only a limited skin or nerve area is numbed and no neuraxial blockade occurs.
Curettage
Definition
Curettage is a surgical procedure in which tissue is mechanically removed or scraped from the uterine cavity using a curette.
Applications and indications
The method is used to remove intrauterine remnants (for example after an abortion or for certain diagnostic questions). It can be part of a dilation-and-curettage procedure (scraping after prior opening of the cervical canal).
Key points
The curette is the instrument used for this; extent and technique depend on the indication and clinical situation.
Contraceptive patch
Basic principle
A contraceptive patch is a combined hormonal contraceptive that delivers hormones through the skin to support pregnancy prevention.
Mechanism of action
Transdermally released hormones generally inhibit ovulation; additionally they alter cervical mucus and the endometrium, making fertilization and implantation more difficult.
Use
Typically the patch is changed weekly and used for three weeks, followed by a one-week break. Different preparations use different progestogens; common patches contain ethinylestradiol and a progestogen (for example norelgestromin).
Important risks and side effects
Possible adverse effects include breast tenderness, nausea, headaches, and local skin reactions at the application site. As with other combined hormonal contraceptives, there is an increased risk of venous thromboembolism.
Ibuprofen
Ibuprofen
Drug class: Nonsteroidal anti-inflammatory drug (NSAID).
Mechanism of action: Inhibits cyclooxygenase enzymes and thereby reduces the formation of prostaglandin-like mediators involved in pain, inflammation, and fever.
Indications: Symptomatic treatment of pain, inflammatory conditions, and fever.
Important risks and side effects: Can cause gastrointestinal complaints up to mucosal damage, increased bleeding tendency, renal dysfunction, and allergic reactions; special caution is required in certain preexisting conditions.
Dosage forms: Available, for example, as tablets, capsules, liquid suspensions, and rectal suppositories.
Paresthesias
Paresthesias
Definition: Abnormal sensations such as tingling, “pins and needles,” or sensory disturbances without an external stimulus.
Causes: Can result from irritation or damage of peripheral nerves, circulatory disorders, metabolic diseases, or allergic reactions.
Clinical significance: Localization, course, and accompanying symptoms are important for differential diagnosis and evaluation of underlying causes.
Joints
Joints
Definition: Hand-rolled smoking units that typically contain cannabis products (e.g., marijuana or hashish) and are often mixed with tobacco.
Form of consumption: Smoked like cigarettes; composition and amount consumed vary depending on preparation and user.
Relevant aspects: Composition, purity, and frequency of use influence potential health and legal consequences.
Environmental technician (female)
Environmental technician (female)
Fields of activity: Advising companies and municipal bodies on environmental protection, waste management, energy savings, and sustainable concepts.
Tasks: Analysis of environmental data, preparation of reports, development of measures, and occasional on-site project support.
Work environment: A mix of office work and field assignments, depending on project requirements.
Pancreatic carcinoma
Pancreatic carcinoma
Definition: Malignant tumor of the pancreas; in adults the disease predominantly arises from the exocrine glandular tissue, often as ductal adenocarcinoma.
Clinical presentation: Symptoms often appear late, so the disease is frequently only detected at advanced stages.
Prognosis: Due to late clinical onset and often aggressive course, the prognosis is generally poor.
Dementia disorder
Definition: Dementia disorders are progressive impairments of higher cognitive functions that affect memory, attention, language, orientation, and activities of daily living.
Clinical features: Affected individuals typically show loss of short-term memory, limitations in coping with everyday tasks, and increasing disorientation; symptoms worsen over time.
Frequency and forms: Alzheimer’s disease is one of the most common causes of dementia, but there are other forms with different underlying changes.
Therapeutic principles: A cure is not currently possible; therapy aims at symptomatic improvement and slowing progression through pharmacological and nonpharmacological measures.
Pharmacological treatment: Drug classes used include acetylcholinesterase inhibitors and NMDA receptor antagonists; these can temporarily stabilize functional abilities or relieve symptoms but also carry side effects that must be weighed individually.
Pelvic carcinoma
Definition: The term lower abdominal carcinoma encompasses malignant tumors in the pelvic/lower abdominal area; these are often gynecological malignancies such as tumors of the uterus, ovaries, or cervix.
Clinical notes: Typical complaints may include unusual vaginal bleeding, lower abdominal or pelvic pain, and a palpable tumor or sensation of pressure; symptoms vary by location and tumor type.
Diagnostics and treatment principles: Workup typically involves imaging procedures, clinical examination, and tissue sampling; treatment depends on tumor type and stage and includes surgical, medical, and/or radiotherapeutic measures.
Important notes: Specific treatment decisions and prognoses depend on the exact histological diagnosis and the extent of spread; general statements therefore need to be specified.
Scotoma
Definition: A scotoma is a defined area in the visual field where vision is reduced or completely absent.
Types: A distinction is made between relative scotomas with partial vision loss and absolute scotomas with complete loss of vision in the affected field.
Causes and significance: Scotomas can arise from diseases of the retina, the optic nerve, or the visual cortex and are an important symptomatic sign of ocular or neurological pathologies.
Clinical context: The occurrence of a scotoma often requires ophthalmological or neurological evaluation to determine the cause, prognosis, and necessary therapy.
COPD
Definition: COPD (chronic obstructive pulmonary disease) is a long-term disease of the airways characterized by persistently impaired exhalation.
Clinical features: Typical complaints are chronic cough, increased mucus production, and exertional dyspnea; lung function is persistently reduced.
Causes and prevention: The most common cause is tobacco smoke; occupational exposures to harmful substances or other inhaled irritants can also contribute. Avoiding risk factors is central to prevention and course control.
Treatment principles: Therapeutic goals are symptom relief, improved exercise tolerance, and prevention of exacerbations; these include smoking cessation, physical activation, vaccinations, inhaled pharmacotherapy, and, if necessary, other supportive measures.
Blood pressure
Term and significance: Blood pressure describes the pressure of the blood in the arterial vessels and is divided into systolic and diastolic components, which are important for organ perfusion.
Measurement: Arterial blood pressure is clinically determined either with a manual device (cuff, inflation bulb, manometer, and stethoscope) using the auscultatory method or with automatic oscillometric devices. Measurement conditions and technique influence the values and must be considered when interpreting results.
Respiratory rate
Definition: Respiratory rate is the number of breaths per unit time and is one of the vital parameters.
Normal range and abnormalities: In adults the respiratory rate usually falls within a characteristic range; deviations upward are called rapid breathing (tachypnea) and downward are called slowed breathing (bradypnea).
Oxygen saturation
Oxygen saturation
Definition: Oxygen saturation describes the proportion of hemoglobin saturated with oxygen relative to total hemoglobin in arterial blood.
Measurement: Saturation is usually measured noninvasively with a pulse oximeter on the finger, earlobe, or toe. The device measures the peripheral oxygen saturation value (SpO2).
Clinical significance: Saturation provides information about the oxygenated hemoglobin concentration and helps detect hypoxemia and assess the need for oxygen therapy or further diagnostics.
Body temperature
Body temperature
Term: Body temperature is a measure of internal heat and an important vital parameter.
Measurement sites and comparison: Different measurement sites yield different values; rectal measurements are considered approximate core temperature. Orally measured values are typically slightly lower than rectal temperature, and axillary measurements are generally even lower. Therefore, results must be interpreted differently depending on the measurement site.
Percussion
Percussion
Purpose: Percussion is used to assess the underlying structures by tapping sounds and helps detect hyperinflation, fluid, or consolidation.
Technique: With a flat finger of the supporting hand on the thorax, the middle finger of the striking hand is snapped briefly from the wrist onto the distal phalanx of the placed finger. The examination is performed systematically, comparing both sides and from cranial to caudal.
Findings: Physiologically, lung tissue filled with air yields a resonant percussion note. An area with increased air content produces a hyperresonant note, while fluid or parenchymal consolidation leads to a dull/muted percussion note.
Auscultation
Auscultation
Purpose: Auscultation serves to directly assess breath sounds and the presence of additional sounds.
Procedure: The lungs are listened to systematically and bilaterally with a stethoscope, usually from dorsal to ventral and from top to bottom. The patient should breathe quietly and deeply through the mouth.
Assessment: The characteristics of breath sounds (e.g., vesicular, bronchial, diminished) as well as adventitious sounds like wheeze, rhonchi, or crackles are evaluated, which can indicate different pathophysiological processes.
Pneumothorax
Pneumothorax
Definition: A pneumothorax occurs when air enters the pleural space, causing loss of the physiological negative pressure and allowing the lung to partially or completely collapse.
Causes: Causes include spontaneous pneumothorax (primary without known lung disease or secondary with lung diseases such as COPD), traumatic injury, and iatrogenic procedures. A tension pneumothorax is a life-threatening form.
Clinical presentation and diagnostics: Clinical signs can include acute dyspnea, unilaterally diminished or absent breath sounds, and a hyperresonant percussion note. Imaging such as chest X-ray, ultrasound, or CT is used for confirmation and to assess extent.
Treatment principles: Treatment depends on size and clinical deterioration and ranges from observation and oxygen therapy to aspiration or placement of a chest drain; immediate decompression is required for tension pneumothorax.
Arterial blood gas analysis
Arterial blood gas analysis in acute exacerbations
Leading signs in the arterial blood gas picture depend on the severity of the airway disease. In mild deterioration there is a decreased arterial oxygen tension (PaO2) combined with a reduced carbon dioxide tension (PaCO2) and a respiratory alkalosis (elevated pH). In moderate courses PaCO2 often remains within the normal range while PaO2 is reduced and pH usually remains unchanged. In severe exacerbation pronounced hypoxemia, an increase in PaCO2, and consequently a respiratory acidosis (reduced pH) occur.
Differential
particularly for determining the eosinophil count
CRP
CRP – C-reactive protein
Brief description: CRP is an acute-phase protein produced in the liver. It serves as a nonspecific marker of inflammation.
Clinical significance: Elevated CRP levels indicate an acute inflammatory or infectious reaction and are used to assess course and differentiate inflammatory processes.
FVC
Forced vital capacity (FVC)
Definition: FVC is the volume of air that can be exhaled forcefully and completely after deepest inhalation.
Significance: FVC is a standard spirometry parameter and is used together with the forced expiratory volume in one second (FEV1) to classify ventilatory disorders.
PatientSalutation: Mr./Ms. Senior physician ……….., I would like to present Ms. Beate Schreiber to you. |
Date05/07/2025 |
| Age36 years | Weight80 kg | Height172 cm |
Allergies (keywords)
Pollen (spring): rhinoconjunctivitis
Nuts (esp. hazelnuts, walnuts): oral paresthesias (lips, tongue)
Substance use / drugs (keywords)
Non-smoker
Alcohol: occasionally 1–2 glasses of beer (on special occasions)
Drugs: occasional joints for 3 months
Social history (keywords)
Environmental technician
lives with partner, marriage planned
no children
Family history (keywords)
Father (76): pancreatic carcinoma (palliative), alcohol abuse
Mother (72): dementia, previous pelvic carcinoma (surgery), scotoma
Medications (keywords)
Ibuprofen 400 mg as needed
Steroid-containing ointment as needed
Transdermal contraceptive patch (Lisvy) for 4 months
History (full sentences)
The patient presented emergently to our clinic due to an acute, paroxysmal dyspnea with a sensation of suffocation that began about four hours earlier.
She additionally reported a dry cough, tachypnea, expiratory wheeze and pronounced agitation.
Due to repeated coughing, the patient complained of breathing-dependent chest pain.
The patient denied the following complaints: fever, signs of infection, hemoptysis, cervical lymphadenopathy and gastrointestinal symptoms.
According to her, the attack lasted about 20 minutes, with the symptoms especially severe for about 10 minutes. The symptoms only improved partially.
She stated that since yesterday she had two similar attacks – one in a tunnel during a traffic jam and another while sleeping around 3 to 4 a.m.
The history notes airway hyperresponsiveness known since childhood. Previous episodes, however, had been markedly milder in duration and intensity.
She reported that when walking in the woods, especially in spring, she often has to cough or sneeze.
Autonomic notable is a targeted diet to relieve flatulence as well as an insomnia after an abortion six months ago.
Other relevant Pre-existing conditions include recurrent eczema in the ear canal, chronic neck pain from sedentary work and a status post panaritium of the right middle finger (therapy: incision, ethacridin lactate dressing, plaster splint).
A left zygomatic bone fracture was treated conservatively seven years ago.
A knee injury with evidence of a free body was also treated arthroscopically.
Gynecological the last bleeding occurred 8 days ago, the cycle is regular. The mentioned abortion at 11 weeks of pregnancy was uncomplicatedly treated by curettage.
Suspected diagnosis – Differential diagnosis (full sentences)
The clinical information in a paroxysmal dyspnea with wheeze and dry cough, a known bronchial hyperreactivity and associated atopic diseases (rhinoconjunctivitis, eczema) suggests bronchial asthma.
Differential diagnoses include panic attacks, early COPD or an allergic immediate reaction.
Further management – Therapy (full sentences)
On physical examination, lung auscultation is especially important, with particular attention to the presence of wheeze and findings to exclude pneumonia or pneumothorax.
At the same time, the patient should be admitted and stabilized with oxygen therapy and administration of bronchodilators.
Subsequently, outpatient spirometry is planned for further diagnostics. In addition, patient education is an essential part of therapy, particularly regarding correct inhaler technique and subsequent mouth rinsing.
Signature
First name Last name
Kind regards
1. Age
2. Sex
3. Main complaint
1. Onset usually before the age of 25
Can occur anew at any age
2. Boys more often affected than girls
3. An attack with acute dyspnea, dry cough, wheeze (whistling breathing, expiratory) as well as anxiety or restlessness.
4. Duration
5. Other points
4. Usually 10–20 minutes.
The attack may also subside without treatment.
A longer attack, however, can lead to exhaustion of the respiratory muscles.
5. Impairment of daily life and physical performance
Nocturnal symptoms
Tachypnea (partly shallow and irregular), use of accessory respiratory muscles, hoarseness
6. Triggers
Physical exertion (exercise-induced asthma)
Cold (winter)
COX-1 inhibitors (e.g., aspirin)
Allergens (e.g., pollen, animal hair, house dust mites)
Irritants (e.g., smoke, exhaust fumes, perfume)
Occupational exposures (e.g., flour dust, chemicals, paints)
Respiratory tract infections
Emotional strain or stress
Without identifiable cause (intrinsic asthma)
7. Atopy
8. Genetics
9. Physical examination
7. Hay fever, atopic eczema
8. Family history (genetic predisposition)
9. Vital signs Elevated respiratory rate (approx. 25–40/min), tachycardia, changes in consciousness, pulsus paradoxus (increased inspiratory fall in systolic blood pressure), oxygen saturation around 90 %
Interictal phase: often clinically inconspicuous
10. Differential diagnosis
Viral infections of the upper/lower respiratory tract, bacterial pneumonia: absence of fever, no constitutional symptoms, not paroxysmal
Bronchitis: after viral infection, self-limiting, spontaneous improvement
Pneumothorax: sudden dyspnea, sharp chest pain
COPD: unlikely (no tobacco use, no dust exposure, young age)
11. Spirometry
Pulmonary function test with spirometer
Patient breathes in and out through a mouthpiece
1. Pre-bronchodilator
2. Administration of bronchodilator: e.g., salbutamol
3. Post-bronchodilator: repeated measurement after approx. 15 minutes
Typical in asthma: obstructive ventilation pattern ↓ FEV₁ and ↓ FEV₁/FVC (< 70 %)
Reversibility: increase in FEV₁ ≥ 12 % and ≥ 200 ml after bronchodilator administration
12. Laboratory diagnostics
13. Chest X-ray
12. (not required between attacks)
Arterial blood gas analysis (ABG), differential blood count, CRP
13. generally not required, only if another diagnosis is suspected (e.g., pneumothorax, pneumonia)
In asthma attack: signs of hyperinflation of the lung
14. Treatment
14. Classification according to symptom frequency (daytime, nighttime) and spirometry
Avoidance of triggering factors (allergens, tobacco smoke, cold, air pollution, occupational exposure)
Promotion of regular physical activity
14. Treatment
Salbutamol (blue): short-acting β₂-agonist (SABA), as-needed medication
Foster (light violet): beclometasone (ICS) + formoterol (LABA)
Symbicort (red): budesonide (ICS) + formoterol (LABA)
Inpatient: + oxygen via nasal cannula (1–4 l/min) + prednisolone 50 mg p.o.
15. Inhaler use
Shake the inhaler well
Remove protective cap
Exhale fully (not into the inhaler)
Place the mouthpiece firmly between the lips
Inhale slowly and deeply, actuate the spray simultaneously
Hold breath for 5–10 seconds
Rinse mouth afterwards
16. Eczema + hay fever
Eczema: typically topical corticosteroid ointments such as hydrocortisone or Advantan
Hay fever
Local:
Nasal spray with mometasone or beclometasone
Eye drops with azelastine or olopatadine
Tablets: Cetirizine, Loratadine, Fexofenadine
17. Complications
Status asthmaticus (life-threatening, prolonged attack that does not respond to the usual initial measures with bronchodilators and corticosteroids)
Pneumothorax
Irreversible bronchial obstruction
Reduced quality of life (exercise tolerance, sleep quality)
Growth retardation (in children, rare)
18. Imagine: How would you typically present a patient with asthma?
The patient presented to the emergency department due to an episode of paroxysmal dyspnea with a feeling of suffocation that began about four hours earlier. She additionally reported an irritating cough, tachypnea, expiratory wheeze, and pronounced restlessness.
As a result of the repeated cough stimulus, the patient complained of pleuritic chest pain that is dependent on breathing.
1. dyspnea
2. wheezing
3. tachypnea
4. bradypnea
5. airway hyperresponsiveness
6. obstruction
7. expiration
8. inspiration
9. sputum
10. hoarseness
11. rhinoconjunctivitis
12. cyanosis
13. bronchitis
14. pneumonia
15. pneumothorax
16. bronchodilator
17. metered-dose inhaler
1. shortness of breath
2. wheezing sound
3. rapid breathing
4. slow breathing
5. sensitive airways
6. narrowing
7. exhalation
8. inhalation
9. expectoration
10. hoarseness
11. nasal and eye inflammation
12. bluish discoloration
13. bronchial inflammation
14. lung inflammation
15. air in the chest cavity
16. bronchodilators
fachleiterinfo@gmail.com
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fachleiterinfo@gmail.com
instagram.com/fachleiterinfo
Basic knowledge
Leading symptom: increased airway resistance
Cause: airway obstruction
Mechanisms:
contraction of the smooth bronchial musculature
thickening of the bronchial epithelium
mucus production → narrowing of the lumen
Symptoms often occur during exhalation because the bronchi collapse more and airway resistance increases during that phase.
To run an AI simulation, download the PDF with the prompt, then upload it to an AI application such as ChatGPT.
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DOCTOR: Hello,
My name is Doctor Lauterbach.
I am working today as a junior doctor on the ward.
I would like to conduct a history-taking interview with you.
If you do not understand something correctly or have questions, please let me know.
First I need some personal information, then we can continue.
What is your name?
PATIENT: My name is Beate Schreiber.
DOCTOR: Did I understand that correctly – Beate, spelled with e and a, right?
PATIENT: That’s right, Doctor.
DOCTOR: First I would like to know whether you can tolerate the pain or symptoms reasonably well.
PATIENT: I feel really bad now.
I just can’t get any air.
Please do something.
DOCTOR: I will first measure your vital signs and then see which treatment suits you best.
We will also give you oxygen so that you can breathe better.
Don’t worry — we will take care of everything immediately.
PATIENT: All right, Doctor.
DOCTOR: Are you feeling better now?
PATIENT: Yes, thank you.
DOCTOR: How old are you, Ms. Schreiber?
PATIENT: I am 36 years old.
DOCTOR: When exactly were you born?
PATIENT: I was born on the fifteenth of July 1989.
DOCTOR: How tall are you?
PATIENT: I am one seventy-two.
DOCTOR: How much do you weigh?
PATIENT: Unfortunately I can’t say exactly, our scale is broken. The last time, about three months ago, it was roughly 80 kilos. But my clothing size hasn’t changed.
DOCTOR: What is the name of your general practitioner?
PATIENT: My GP is Doctor Karla Scholz.
DOCTOR: Can you tell me a bit more about your complaints?
PATIENT: Today I suddenly had a lot of trouble breathing — like a real attack.
It felt as if someone was strangling the air out of me. I also had to cough.
DOCTOR: Since when have you had the symptoms?
PATIENT: It started about four hours ago.
Also, I had two similar attacks yesterday.
Once in the tunnel on the way home in the car, the second was during sleep, around 3 or 4 in the morning.
DOCTOR: Are the symptoms constant or do they occur in phases?
PATIENT: The symptoms probably eased after about 20 minutes, but they didn’t disappear completely. About ten minutes of that were really distressing.
DOCTOR: Did the symptoms start suddenly or rather slowly?
PATIENT: The symptoms started suddenly each time.
DOCTOR: Could you describe the attacks in a bit more detail, please?
PATIENT: Last night I had an attack while I was stuck in traffic driving through a tunnel.
Suddenly I had a lot of trouble getting air – it was really unpleasant.
When we got out of the tunnel, I opened the side window, then it got better, and fortunately it finally improved on its own. Later, when I was asleep, I suddenly woke up because of a strong tightness in the chest and coughing.
DOCTOR: Did you have to wait a long time in the tunnel?
PATIENT: Yes, about three quarters of an hour.
DOCTOR: Were the windows in the bedroom open?
PATIENT: Yes, in summer our windows are actually always open – otherwise it doesn’t work at all.
DOCTOR: How many pillows do you need to sleep?
PATIENT: I have been using two pillows for a long time, but that has nothing to do with shortness of breath.
I just find it more comfortable that way.
DOCTOR: Is there anything that worsens or improves the cough, e.g. a certain body position or activity?
PATIENT: When I calmed down and opened the window, the symptoms improved.
Fresh air generally does me good.
DOCTOR: Do you have chest pain?
PATIENT: Because I had to cough heavily during the attacks, I had chest pain afterwards.
I suspect that this pain was caused by the repeated coughing.
DOCTOR: You are right.
Are you breathing faster or slower than usual?
PATIENT: I have the impression that I am breathing a bit faster – especially during the attacks.
However, it does not feel like normal, effective breathing.
DOCTOR: Have you noticed palpitations, pounding heart, or irregular heartbeats?
PATIENT: No, I haven’t noticed such symptoms.
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DOCTOR: Is your cough dry, or do you bring up sputum?
PATIENT: Well, most of the time it’s dry, but sometimes a bit of mucus comes up.
You know, about three weeks ago I had the flu.
Could that be related?
DOCTOR: Yes, that’s quite possible – but it doesn’t have to be the only cause.
After an influenza-like infection, a dry cough like yours, which is not too severe, can persist for one to two months. That means this could also have been a trigger.
The important thing is that the symptoms improve on their own over time.
We will, however, investigate this carefully to be able to make a confirmed diagnosis.
What does the mucus look like – rather clear or yellowish? Have you noticed any blood?
PATIENT: It’s transparent and a bit glossy. No, I haven’t seen any blood.
DOCTOR: Do you have hoarseness or a sore throat?
PATIENT: At the moment I have neither hoarseness nor a sore throat.
But about three weeks ago, when I had the flu, I had a sore throat and fever, but the symptoms have since significantly improved.
My colleagues also had the flu, although a bit shorter than mine.
I always wore a mask, but I don’t know where I got infected.
DOCTOR: Cold and flu viruses are mostly transmitted by droplets – for example when someone coughs or sneezes.
In reality, however, you also often get infected via the hands or via objects that someone else has touched.
That’s why it’s important to disinfect your hands regularly – preferably with an alcohol-based product.
That way you can avoid infection well
PATIENT: Thank you very much, doctor, an interesting tip.
DOCTOR: Do you hear wheezing or buzzing when breathing in or out?
PATIENT: Yes, especially during the attacks I hear a wheezing sound when exhaling.
DOCTOR: Have you had such problems before?
PATIENT: Yes, I’ve actually had that since childhood. I have sensitive airways and used to have attacks more often – mostly with coughing that lasted two or three minutes.
But it has never been as bad as now.
I often walk in the woods, and sometimes I then get a cough and have to sneeze – especially in spring when the pollen are flying.
But it has never been as bad as now.
DOCTOR: Have you noticed a tickle in the throat?
PATIENT: Sometimes I have a tickle in the throat that usually occurs before the cough or an attack.
DOCTOR: Do you have a blocked or runny nose?
PATIENT: At the moment I don’t, but in spring, when everything starts blooming, the hay fever begins.
DOCTOR: What exactly do you mean by hay fever?
What symptoms do you then have?
PATIENT: Mainly a blocked nose and watery eyes.
Sometimes I also have to sneeze or my eyes itch.
DOCTOR: What do you do about it?
PATIENT: I wear a mask.
But sometimes the symptoms are still quite severe.
DOCTOR: You can also take a medicine like loratadine or cetirizine about one to two hours before contact with the pollen – that helps quite well.
Do you have headaches?
PATIENT: No, I don’t have headaches.
DOCTOR: How do you feel during the attacks?
PATIENT: The shortness of breath really scares me during the attacks.
I also feel like my lungs are inflating and I can’t get the air out properly.
DOCTOR: Do you have someone with you?
PATIENT: Yes, my partner is coming shortly.
He is on his way here.
DOCTOR: Do you have fever, night sweats or chills?
PATIENT: Nothing.
DOCTOR: How is your appetite?
PATIENT: I have a good appetite and no particular restrictions.
DOCTOR: How do you eat – vegan, vegetarian or do you eat everything?
PATIENT: I generally enjoy eating everything.
DOCTOR: Do you have difficulty falling asleep or staying asleep?
PATIENT: For about 6 months it often takes me a very long time to fall asleep.
DOCTOR: Why do you suffer from that?
PATIENT: At night many thoughts are running through my head, and that prevents me from falling asleep.
About six months ago I lost a pregnancy – I just can’t get over it.
DOCTOR: That is really sad.
I’m sorry you had to go through that.
DOCTOR: Could you tell me in which week of pregnancy that happened?
PATIENT: That was in the eleventh week.
It was found during the ultrasound examination that the heart had stopped beating.
DOCTOR: What treatments were carried out at that time?
PATIENT: The uterus was carefully emptied under anesthesia.
DOCTOR: Do you still know what kind of anesthesia that was?
PATIENT: The doctors evacuated the uterus under anesthesia, so they did a curettage.
Page 3 · 41–60 / 92
DOCTOR: Were there any complications during or after that?
PATIENT: No, not really.
But the surgeon told me that scars could form later.
DOCTOR: What do you do when you sleep poorly at night?
PATIENT: I usually drink an herbal tea to calm down a bit.
That helps sometimes a little.
DOCTOR: How do you feel in the morning? Are you rather drowsy or do you have headaches?
PATIENT: Sometimes I have morning headaches, but not strong ones.
DOCTOR: Do you have difficulty with bowel movements or urination?
PATIENT: For about two years I’ve had recurring problems with bloating – especially after eating.
Sometimes there’s also a feeling of fullness.
That’s why I’ve been following a special diet for four months, avoiding bloating foods like legumes, cabbage or heavily spiced dishes.
DOCTOR: Wonderful. Do you suffer from chronic illnesses such as high blood pressure, diabetes or elevated blood lipids?
PATIENT: I’ve had this since my childhood.
Repeated problems in the ear – especially in the ear canal.
It then itches a lot, is sometimes dry or flakes.
DOCTOR: In which situations does it get worse?
PATIENT: When water gets into the ear – for example when swimming – or when I scratch or go in with a cotton swab, it usually gets worse.
DOCTOR: What do you do about it?
PATIENT: I try to keep the ear dry and not to scratch.
Sometimes I use an ointment that the ENT doctor once prescribed to me.
That helps quite well when it gets worse.
DOCTOR: What is the name of the ointment you use?
PATIENT: I use an ointment with cortisone, but I don’t know the exact name right now.
DOCTOR: Do you have skin problems in other places as well – for example on your hair, eyebrows or hands?
PATIENT: Yes, in winter my hands always get very dry – sometimes so much that cracks form.
DOCTOR: Do you use the same ointment for your hands as for your ear?
PATIENT: Yes, that actually helps quite well there too.
DOCTOR: Is there anything else?
PATIENT: Yes, about two months ago I had a paronychia on my finger.
That was quite painful.
DOCTOR: Which finger was that exactly?
And which hand?
PATIENT: It was the middle finger of the right hand – quite close to the nail.
DOCTOR: How was that treated?
PATIENT: The doctor cut it open a bit so the pus could come out, and then flushed it.
After that I got a moist dressing – and the finger was immobilized with a splint.
I have also had neck pain for about five years.
My orthopedist said it comes from sitting a lot – it’s job-related.
DOCTOR: Have you noticed any tingling, numbness or weakness in your hands or arms with that?
PATIENT: No, nothing at all.
DOCTOR: What do you do for a living?
PATIENT: I am self-employed – I work as an environmental technician.
DOCTOR: Could you tell me a bit about what you do exactly?
PATIENT: I advise companies and also municipalities – for example on environmental protection, waste disposal, energy saving or sustainable concepts.
I work a lot at a desk, write reports, analyze data and sometimes accompany projects on site.
DOCTOR: What do you take for the neck pain?
PATIENT: I take ibuprofen as needed.
DOCTOR: In what dosage?
PATIENT: in a dosage of 400 milligrams
DOCTOR: Have you had an MRI of your neck?
PATIENT: No, not so far.
DOCTOR: Have you ever had an accident in the past?
PATIENT: Yes, seven years ago I had a zygomatic fracture.
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DOCTOR: Which side was affected?
PATIENT: The left side.
DOCTOR: How did that happen?
PATIENT: I got hit quite hard in the face by a volleyball – the zygomatic bone broke.
DOCTOR: How was that treated back then?
PATIENT: Fortunately without surgery.
DOCTOR: Have you ever had surgery or undergone a medical procedure?
PATIENT: Yes, I once had an arthroscopy.
DOCTOR: Why was that done?
PATIENT: I injured my right knee playing volleyball.
The pain didn’t go away.
After the MRI they then saw that there was a loose body in the joint.
DOCTOR: When was that exactly?
PATIENT: That was four years ago.
DOCTOR: And did the surgery help?
PATIENT: Yes, definitely – it’s much better now.
DOCTOR: Are you taking any other medications?
PATIENT: I use a contraceptive patch.
DOCTOR: Do you know what it’s called?
PATIENT: I think it’s called Lisvy
DOCTOR: Since when have you been using the patch?
PATIENT: For about two months.
DOCTOR: Do you have any complaints at the site where you stick the patch?
PATIENT: No, everything is fine there.
DOCTOR: Do you have a prescription for your medications?
PATIENT: Yes, I do.
DOCTOR: Are you fully vaccinated, meaning have you received all vaccinations since childhood?
PATIENT: I would say I’m vaccinated against Covid and TBE. I would have to check the rest in my yellow vaccination card.
DOCTOR: When was your last bleeding?
PATIENT: Eight days ago.
DOCTOR: Have there been any problems with your period or other complaints recently?
PATIENT: No, everything is normal.
DOCTOR: Do you have any known allergies or intolerances, for example to certain foods, medications, animal hair or other substances? Apart from pollen?
Yes, I react to nuts.
DOCTOR: How does the allergy present itself for you?
PATIENT: I get a kind of fuzzy feeling on my lips and on my tongue – sometimes it also starts to itch slightly.
DOCTOR: Do you know which nuts exactly you react to?
PATIENT: Mostly to hazelnuts and walnuts – usually nothing happens with almonds.
DOCTOR: Do you smoke?
PATIENT: No, I am a non-smoker.
DOCTOR: Do you drink alcohol?
How often, how much and what exactly do you drink?
PATIENT: Only on special occasions, for example at parties – then I might drink one or two glasses of beer.
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DOCTOR: May I ask if you have ever used drugs?
PATIENT: Occasionally I use cannabis at the weekend in the form of joints.
DOCTOR: Thank you for your openness.
What exactly do you mean by ‘occasionally’?
PATIENT: About sometimes once a month
DOCTOR: Since when have you been smoking joints?
PATIENT: For about three months.
DOCTOR: Who do you live with?
Where do you live?
PATIENT: I live with my partner in an apartment.
We plan to get married in the next few months.
DOCTOR: How many children do you have?
PATIENT: I have no children.
DOCTOR: Are there significant illnesses in your family, for example in your parents, siblings or other close relatives?
PATIENT: My father is 76 years old and has had pancreatic cancer for about eight months.
He used to drink a lot of alcohol.
Because the disease was already very advanced, no surgery and no radiation or chemotherapy were performed.
He is currently receiving pain therapy and palliative care.
My mother is 72 years old, has advanced dementia and lives in a nursing home.
At 52 she underwent surgery for a gynecological cancer after complaining of heavy bleeding and abdominal pain.
She also had a temporary visual field defect.
DOCTOR: I’m sorry to hear that. That must be very stressful for you when both parents are affected healthwise.
Do you know what caused the visual field issue?
No, I don’t know the exact details.
DOCTOR: Do you remember which eye was affected?
PATIENT: I think it was the right eye.
She said she suddenly saw a dark spot there.
DOCTOR: Was that treated back then?
PATIENT: what exactly – I unfortunately don’t remember anymore.
DOCTOR: Have you traveled recently?
PATIENT: No, I haven’t traveled recently.
DOCTOR: Do you have pets?
PATIENT: No, none.
DOCTOR: We are finished with the medical history.
Do you have any questions?
PATIENT: Why are the seizures worse now than before?
Could it happen again?
DOCTOR: There can be several reasons for that.
Sometimes asthma worsens due to infections, allergies, stress, or if medications are not taken regularly.
Weather changes or physical exertion also play a role.
Yes, unfortunately it can happen again — but together we can do a lot to reduce the risk.
It is important that the treatment is well adjusted, that you take your medications regularly, and that you know what to do in an emergency.
Now I will perform a physical examination to assess your current health status more precisely.