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Name
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Lola Mindy
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DOB
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20/07/1991 (23 years)
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Occupation
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Hairdresser
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History
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I am unbelievably talkative and will
not stop talking about irrelevant details unless I am interrupted. I began
having this sharp chest pain since this morning. I am convinced it is a
pulled muscle from hockey practice so I just want painkillers, even though I
haven't really been playing regularly for the last week (if asked: since I
tore my ACL in my knee). It started quite suddenly and doesn't move anywhere.
It's been there all the time and hasn't really changed since this morning.
It's a little worse when I take a deep breath in or when I've been coughing.
I don't think there's any blood or anything else when I have been coughing. I
have also quite been feeling quite breathless. Changing position and exertion
doesn't change the pain. It's about an 8/10. If specifically asked, yes I
have a dull pain in my leg and tender, swollen and a little red but that's
because of the surgery, right? I have not had any other symptoms including
chest tightness, loss of consciousness, nausea or vomiting, fever or recent infections.
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Past Medical History
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Nil apart from in hospital for ACL
injury (had surgery to repair)
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Drug History
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Oral contraceptive pill
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Family History
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Nil
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Social History
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I do not smoke but I drink every
weekend with my hockey buddies in excess. I travelled three weeks ago to a
game in France by coach. I have not been too mobile since the surgery.
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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 associated symptoms of
nausea, vomiting and shortness of breath
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0
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1
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2
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Asks for palpitations, fever, cough
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0
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1
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Excludes heartburn and abdominal pain
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0
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1
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Enquires about exacerbating factors
including physical activity, lying down, coughing and chest tenderness
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0
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1
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2
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Enquires about alleviating factors
including rest, leaning forward, painkillers
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0
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1
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Asks patient to rate 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 illnesses
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0
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1
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Asks specifically for recent illness,
surgery and calf pain or leg swelling
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0
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1
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2
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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 any pulmonary embolisms or clots
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0
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1
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2
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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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2
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Asks about diet and lifestyle
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0
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1
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Asks about any recent travel
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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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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 embolism, pneumonia, anxiety, musculoskeletal pain etc.)
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0
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1
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