Print
PDF
Name
|
Baljit Kaur
|
DOB
|
10/04/1989 (25 years)
|
Occupation
|
Postman
|
History
|
I am very anxious as 3 days ago I
began experiencing a sharp pain in my chest that lasts a few seconds each
time. I am convinced that I am having a heart attack like my father had. It
is right over my heart. It moves to the neck. The pain is worse when I cough
or lie down. It is better when I lean forward. I have no other symptoms. It
is around 6/10 in severity. Yesterday I took some paracetamol which helped.
If asked, admits to having the flu last week with symptoms of fatigue, fever,
cough and runny nose.
|
Past Medical History
|
Nil
|
Drug History
|
Occasional paracetamol
|
Family History
|
Father died of heart attack 2 weeks
ago
|
Social History
|
I do not smoke and I drink
occasionally. I have been quite stressed since my father passed away because
I am worried I will also have a heart attack. I used to exercise a lot but I
have recently let myself go. I used to walk a lot on the job but now I have
to use a van. I don't take any recreational drugs.
|
Introduces yourself
|
0
|
1
|
|
Confirms name & age of patient
|
0
|
1
|
|
Explains reason for consultation
& builds rapport
|
0
|
1
|
|
Gains consent
|
0
|
1
|
|
Asks open question
|
0
|
1
|
|
Establishes site
|
0
|
1
|
|
Asks about onset
|
0
|
1
|
|
Elicits character of pain
|
0
|
1
|
|
Asks if pain radiates
|
0
|
1
|
|
Asks for associated symptoms of
fever, cough and nausea
|
0
|
1
|
2
|
Asks for associated symptoms of
shortness of breath, palpitations,loss of consciousness
|
0
|
1
|
2
|
Excludes heartburn and abdominal pain
|
0
|
1
|
|
Enquires about exacerbating factors
including physical activity, lying down, coughing and chest tenderness
|
0
|
1
|
2
|
Enquires about alleviating factors
including rest, leaning forward, painkillers
|
0
|
1
|
|
Asks patient to rate severity of pain
|
0
|
1
|
|
Asks about previous chest pain
|
0
|
1
|
|
Asks about recent illnesses
|
0
|
1
|
|
Asks specifically for recent illness,
surgery and calf pain or leg swelling
|
0
|
1
|
2
|
Asks about any family history of
disease
|
0
|
1
|
|
Asks specifically if any family
members have had any pulmonary embolisms or clots
|
0
|
1
|
2
|
Establishes any drugs patient is on
|
0
|
1
|
|
Asks if patient has any allergies
|
0
|
1
|
|
Asks if patient smokes, drinks or
takes recreational drugs
|
0
|
1
|
2
|
Asks about diet and lifestyle
|
0
|
1
|
|
Asks about any recent travel
|
0
|
1
|
|
Elicits patients occupation
|
0
|
1
|
|
Explores and responds to ideas
|
0
|
1
|
|
Explores and responds to concerns
|
0
|
1
|
|
Explores and responds to expectations
|
0
|
1
|
|
Shows empathy
|
0
|
1
|
|
Avoids jargon
|
0
|
1
|
|
Summarises back to patient
|
0
|
1
|
|
Thanks patient
|
0
|
1
|
|
Patient global score
|
0
|
1
|
2
|
Gives reasonable differential
diagnosis (pericarditis, anxiety, musculoskeletal etc)
|
0
|
1
|