Print
PDF
Name
|
Korvin Wuest
|
DOB
|
14/03/93 (21 years)
|
Occupation
|
Student
|
History
|
I have exams coming up and I am very
anxious about them. I believe I have the flu and I need antibiotics otherwise I will
not be able to revise. I claim that it just will not go (if pressed has lasted 3 months
and is only getting worse). I feel breathless a lot of the time, especially
outside in the cold or at night where my chest feels a little tight too.
Nights are really bad because I also cough so much but I don't bring up any
sputum or blood. I always get infections every winter, I don't know why, but
I wasn't this bad last winter. If specifically asks admits to an odd sound
when I breathe out which I cannot describe. Denies any history of eczema,
fever, contact with animals, contact with people with similar symptoms,
travel, fainting and any other symptoms.
|
Past Medical History
|
Hayfever. Nil else including no
recent surgery
|
Drug History
|
Paracetamol for recent symptoms. Nil
else
|
Family History
|
Younger sister with eczema. Nil else.
|
Social History
|
Moved to a new flat in 2 months ago
(October) where a flatmate currently smokes. I believe I would have good
support from flatmates should I have an asthma attack. Nil smoking, drugs,
alcohol.
|
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
|
|
Asks about onset (gradual/sudden)
|
0
|
1
|
|
Asks about duration and changes to
breathlessness
|
0
|
1
|
|
Enquires about exacerbating factors
including exertion, chemicals/pollen, lying flat
|
0
|
1
|
2
|
Asks about variability over the day:
constant/progressively worse/worse in the morning or night and seasonal
variation
|
0
|
1
|
2
|
Enquires about severity by asking
about exercise tolerance on flat and up stairs and on rest
|
0
|
1
|
2
|
Asks about any recent illness or
surgery or previous shortness of breath
|
0
|
1
|
|
Asks for cough and sputum and if
present explores further
|
0
|
1
|
2
|
Asks for orthopnoea and paroxyasmal
nocturnal dyspnoea and if present explores further
|
0
|
1
|
|
Asks for added breath sounds such as
wheeze and if present explores further
|
0
|
1
|
|
Asks for chest pain and characterises
chest pain if present
|
0
|
1
|
|
Asks for any fever or contact with
anyone with similar symptoms or sick animals
|
0
|
1
|
|
Asks for any palpitations or
dizziness
|
0
|
1
|
|
Checks for red flags: haemoptysis,
weight loss, night sweats and hoarseness
|
0
|
1
|
2
|
Checks if patient is current or
ex-smoker and number of pack years
|
0
|
1
|
2
|
Asks about past medical history
(specifically hayfever, eczema)
|
0
|
1
|
2
|
Asks about any family history of
disease (specifically eczema, asthma)
|
0
|
1
|
|
Establishes any drugs or over the
counter medication patient is on
|
0
|
1
|
|
Asks if patient has any allergies or
any new pets
|
0
|
1
|
2
|
Asks if patient drinks or takes
recreational drugs
|
0
|
1
|
|
Elicits patients occupation
|
0
|
1
|
2
|
Asks if patient has travelled
anywhere recently
|
0
|
1
|
|
Explores impact of shortness of
breath on activities of daily living
|
0
|
1
|
2
|
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 (asthma, pneumonia, allergic rhinitis)
|
0
|
1
|