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Name
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Cole Abbe
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DOB
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03/04/1941 (74 years)
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Occupation
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Healthcare assistant
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History
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I have had a chronic cough for the
last 6 months and now I am fed up of it. I don\'t bring anything up with it.
It occurs all the time and I have never brought up any blood. I have not noticed
any shortness of breath but do find I tire more easily with exercise. If
asked directly I have noticed some hand and foot joint pain, but assumed that
was due to old age. I deny any dryness of my eyes or mouth, whitening or pain
in my hands in the cold or any other symptoms.
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Past Medical History
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Nil
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Drug History
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Nil
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Family History
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Both parents died young in a horrific
road traffic accident.
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Social History
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5 cigarettes per day. Occasional
alcohol. No recreational drug use. Exposure to asbestos in previous house.
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Introduces yourself
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes onset and duration
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0
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1
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Asks for variability in the day e.g.
diurnal/worse at night (asthma)
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0
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1
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Asks for alleviating factors (e.g.
being at home/work)
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0
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1
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Asks for exacerbating factors (e.g.
exercise, seasonal (asthma, COPD), pollen (asthma), chemicals, posture)
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0
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1
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2
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Establishes if dry or productive
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0
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1
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Establishes severity and impact on
life
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0
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1
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Asks about any recent illnesses
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0
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1
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Screens for red flags (haemoptysis,
weight loss, hoarseness, night sweats)
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0
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1
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Screens for associated respiratory
symptoms (fever, shortness of breath, wheeze, chest pain - clarifying if
pleuritic/burning suggestive of reflux disease)
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0
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1
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2
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Screens for associated cardiovascular
symptoms (orthopnoea, ankle oedema, calf pain or swelling)
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0
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1
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Screens for ENT associated symptoms
(throat, coryza, rhinitis)
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0
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1
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Screens for musculokeletal and
rheumatological symptoms (arthralgia, morning stiffness)
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0
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1
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Elicits past medical history
(specifically asthma, tuberculosis) and recent surgery
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0
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1
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Elicits family history (specifically
asking for atopy, tuberculosis, pulmonary fibrosis, clotting problems)
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0
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1
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Elicits drug history (including use of
ACE inhibitors, beta-blockers, methotrexate)
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0
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1
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Checks for allergies
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0
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1
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Checks if patient smokes or drinks
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0
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1
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Checks occupation of patient
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0
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1
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Asks if occupation or other involves
exposure to dust or animals
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0
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1
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Asks for exposure to asbestos
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (Pulmonary fibrosis possibly secondary to asbestosis or connective
tissue disease, Asthma)
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0
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1
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