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Name
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Fatima Ahmad
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DOB
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07/06/1974 (41 years)
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Occupation
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Decorator
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History
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I have been coughing for almost two
months now bringing up yellow-greenish sputum. If asked directly, at first I
thought it was a chest infection but even after antibiotics from the GP that
never cleared up. It is pretty severe all day and night and interferes with
my sleep. I also wake up with night sweats. There\'s occasionally been a pink
tinge to my sputum and I have had a kilogram of weight loss over the last 2
months. I travelled to India around 3 months ago and lived with my family in
a crowded flat. I don\'t remember any of them being ill. I deny any other
symptoms. I am convinced it is cancer due to my smoking.
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Past Medical History
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Nil
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Drug History
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If asked directly, took a course of
unknown antibiotics recently
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Family History
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Father had heart attack at 45 years.
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Social History
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10 cigarettes per day. Occasional
alcohol. No recreational drug use.
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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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Elicits character of sputum
(bloodstained, clots, green/yellow, offensive smell)
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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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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 (Tuberculosis, Atypical pneumonia, Bronchiectasis)
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0
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1
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