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Name
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Ramsay Tucker
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DOB
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13/08/42 (72 years)
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Occupation
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Retired Mechanic
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History
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For the last 2 months I have been
feeling more breathless, particularly when I do any form of activity. I can
only walk around 50 metres now where as 3 months ago I was fine! I don't feel
breathless when I have been resting though unless I'm lying down when it can
get so bad I wake up gasping for breath. I haven't noticed any wheeze or
other odd breath sounds. I have a cough with some frothy sputum but no blood.
Also been feeling some nausea from time to time. I have also had some leg
swelling for around the same time. I deny any other symptoms including chest
pain, palpitations, fever, night sweats or weight loss.
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Past Medical History
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Previous heart attack 4 years ago.
Hypertension, diabetes, high blood cholesterol. Nil else.
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Drug History
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Aspirin, Ramipril, Simvastatin
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Family History
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Father died of heart attack at 60.
Nil else.
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Social History
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I am an ex-smoker that used to smoke
10 a day for 40 years. Nil alcohol or recreational drug use. I am having a
lot of trouble with my daily activities. I cannot shop or dress myself among
many other things.
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Introduces self
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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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Asks about onset (gradual/sudden)
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0
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1
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Asks about duration and changes to
breathlessness
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0
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1
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Enquires about exacerbating factors
including exertion, chemicals/pollen, lying flat
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0
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1
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2
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Asks about variability over the day:
constant/progressively worse/worse in the morning or night
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0
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1
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Enquires about severity by asking
about exercise tolerance on flat and up stairs and on rest
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0
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1
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2
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Asks about any recent illness or
surgery or previous shortness of breath
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0
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1
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Asks for cough and sputum and if
present explores further
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0
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1
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2
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Asks for orthopnoea and paroxyasmal
nocturnal dyspnoea and if present explores further
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0
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1
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Asks for added breath sounds such as
wheeze and if present explores further
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0
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1
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Asks for chest pain and characterises
chest pain if present
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0
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1
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Asks for ankle oedema
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0
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1
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Asks for any fever or contact with
anyone with similar symptoms
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0
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1
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Asks for any palpitations or
dizziness
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0
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1
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Checks for red flags: haemoptysis,
weight loss, night sweats and hoarseness
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0
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1
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2
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Checks if patient is current or
ex-smoker and number of pack years
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0
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1
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2
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Asks about past medical history
(specifically COPD and heart attacks)
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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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Establishes any drugs or over the
counter medication 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 drinks or takes
recreational drugs
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0
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1
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Elicits patients occupation and any
possible exposure to asbestos
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0
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1
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Asks if patient has travelled
anywhere recently
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0
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1
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Explores impact of shortness of
breath on activities of daily living
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0
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1
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2
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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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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 (congestive heart failure, valve disease, nephrotic syndrome)
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0
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1
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