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Name
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Andrew Clark
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DOB
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09/11/1963 (52 years)
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Occupation
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Financial director
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History
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I am quite frustrated to have been kept waiting, as I am very important within my firm and cannot afford to waste time. I have been experiencing pain in the centre of
my chest for 2 months, however I do not think this is a big deal. It affects me when I exert myself, doing things such as running to catch a bus or walking briskly particularly when it is cold. Once I sit down, the pain resolves quite quickly. The pain has worsened over the last 2 months and is about 4-5/10, however it does not occur at rest. The pain does not move anywhere. I have not had any shortness of breath, palpitations, nausea, vomiting, cough, fever or any other symptoms.
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Past Medical History
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I have never been tested for diabetes or had my cholesterol checked. My blood pressure is high so I have been trying to cut down on my salt. I have no other medical conditions.
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Drug History
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Nil
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Family History
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My parents both had diabetes. My mother died of a stroke and my father died of a heart attack in his early fifties. I don't have any siblings. There are no other medical conditions that run in the family.
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Social History
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I smoke 20 cigarettes a day. I have to drink quite frequently when I see clients or go out after work. I am not sure exactly how much I drink but it's probably not a lot. I don't take any recreational drugs. I don't exercise much and my diet consists of a lot of take outs because I am very stressed for time.
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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 site
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0
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1
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Asks about onset
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0
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1
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Elicits character of pain
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0
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1
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Asks if pain radiates
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0
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1
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Asks for nausea and sweating
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0
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1
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2
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Asks for shortness of breath
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0
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1
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Asks for palpitations
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0
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1
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Excludes loss of consciousness and
dizziness
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0
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1
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2
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Excludes heartburn
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0
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1
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2
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Asks for fever, cough
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0
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1
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Asks for heartburn/abdominal pain
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0
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1
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Enquires about exacerbating factors
including physical activity
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0
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1
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Enquires about alleviating factors
including rest
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0
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1
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Asks about duration and changes to
pain over time
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0
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1
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Checks severity of pain
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0
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1
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Asks about previous chest pain
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0
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1
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Asks about recent illness and past
medical history
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0
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1
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2
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Asks specifically for previous heart
disease, stroke, diabetes, high cholesterol, hypertension and asthma
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0
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1
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Asks about any family history of
disease
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0
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1
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Asks specifically if any family
members have had cardiac disease below <55 years, cardiac disease,
pulmonary embolism or sudden death
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0
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1
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Establishes any drugs patient is on
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0
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1
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Asks if patient has any allergies
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0
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1
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Asks if patient smokes, drinks or
takes recreational drugs
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0
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1
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Asks about diet and lifestyle
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0
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1
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Elicits patients occupation
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0
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1
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Explores and responds to ideas
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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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2
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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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1
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Summarises back to patient
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1
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Thanks patient
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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 (angina pectoris, aortic valve disease, myocardial infarction)
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0
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1
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